FOOD INSECURITY SCREENING IN HOUSTON AND HARRIS COUNTY: A GUIDE FOR HEALTHCARE PROFESSIONALS

Transcription

1 FOOD INSECURITY SCREENING IN HOUSTON AND HARRIS COUNTY: A GUIDE FOR HEALTHCARE PROFESSIONALS DECEMBER 2017

2 Authors Lead Author Nancy P. Correa, MPH Department of Pediatrics, Baylor College of Medicine and Texas Children s Hospital npcorrea@texaschildrens.org Contributing Authors Stephanie Berno, MS, RD, LD Houston Food Bank, Nutrition Education sberno@houstonfoodbank.org Suratha Elango, MD, MSHP Department of Pediatrics, Baylor College of Medicine and Texas Children s Hospital suratha.elango@bcm.edu Harry C. Hadland, IV Houston Food Bank, Food for Change hhadland@houstonfoodbank.org Tanweer Kaleemullah, JD, LLM, MHA/MBA Harris County Public Health, Office of Policy & Planning Tanweer.Kaleemullah@phs.hctx.net Felicia Latson, LCSW Legacy Community Health flatson@legacycommunityhealth.org Elizabeth LoCaste Memorial Hermann Community Benefit Corporation Stephanie Marton, MD, MPH Department of Pediatrics, Baylor College of Medicine and Texas Children s Hospital samarton@texaschildrens.org Ana C. Monterrey, MD, MPH Department of Pediatrics, Baylor College of Medicine and Texas Children s Hospital Ana.Monterrey@bcm.edu Jill R. Roth, MD Department of Pediatrics, Baylor College of Medicine and Texas Children s Hospital jrroth@texaschildrens.org Padma Swamy, MD, MPH Department of Pediatrics, Baylor College of Medicine and Texas Children s Hospital swamy@bcm.edu Reginald Young, MA Houston Food Bank, Food for Change ryoung@houstonfoodbank.org 2

3 ACKNOWLEDGEMENTS This report was developed by the participants of the Adverse Childhood Experiences-- Food Insecurity Workgroup. We are grateful and appreciative of the following workgroup members and community partners that provided expertise, knowledge, and resources for this report. Linsi Broom, MS, Houston Health Department; Kristin L. Dupeire, LCSW-S, Legacy Community Health; Lawrence J. Frye, Consultant to GE; Beverly J. Gor, EdD, RD, LD, Houston Health Department; Christopher S. Greeley, MD, MS, FAAP, Department of Pediatrics, Baylor College of Medicine and Texas Children s Hospital; Jennifer M. Hadayia, MPA, Harris County Public Health; Judy Levison, MD, MPH, Department of Obstetrics and Gynecology, Baylor College of Medicine; Kimberly Kay Lopez, DrPH, MPH, Department of Pediatrics, Baylor College of Medicine and Texas Children s Hospital; Casandra Quinones, MD, Department of Pediatrics, Baylor College of Medicine and Texas Children s Hospital; Maryiam Saifuddin, Houston Food Bank; Shreela V. Sharma, PhD, RD, LD, UTHealth School of Public Health; and Toral Sindha, MBA, RD, LD, Clinton Health Matters Initiative. Participating organizations Recommended citation: Correa, N. and the ACE Coalition Food Insecurity Workgroup. Food insecurity screening in Houston and Harris County: A Guide for Healthcare Professionals. Houston, TX: Baylor College of Medicine and Texas Children s Hospital, Available at: 3

4 Table of Contents EXECUTIVE SUMMARY... 5 INTRODUCTION... 7 BACKGROUND... 7 SCREENING FOR FOOD INSECURITY... 8 INTEGRATING FOOD INSECURITY SCREENING INTO YOUR HEALTH CARE PRACTICE... 9 INTERVENTIONS AND RESOURCES...14 LOCAL SPOTLIGHTS...16 COLLECTING DATA AND EVALUATION...17 SUSTAINABILITY: FUNDING FOOD INSECURITY SCREENING AND REFERRAL PROGRAMS...19 LIMITATIONS...19 SPECIAL POPULATIONS AND CONSIDERATIONS...20 RECOMMENDATIONS...21 REFERENCES APPENDIX A: RESOURCES FOR FOOD INSECURITY...25.Federal nutrition programs...25 Local resources...26.farmers markets that accept SNAP/EBT...27.Local resources for food insecure children...27.local resources for food insecure seniors...28.disaster resources...29.national resources...29 APPENDIX B. HARRIS COUNTY BUILD PARTNERSHIP S FOOD PRESCRIPTION

5 EXECUTIVE SUMMARY Food insecurity impacts millions of Americans each year. It occurs when households do not have reliable access to nutritionally adequate or safe foods. There are an estimated 724,750 food insecure individuals in Harris County with a food insecurity rate of 16.6%. Among children, the rate of food insecurity is 23.6%. Food insecurity can have significant negative implications on a person s health, including higher rates of chronic diseases and mental health problems. As a result, healthcare providers, academics, local nonprofits, public health professionals, and local government agencies in Houston, TX and Harris County formed a workgroup to address food insecurity screening in healthcare settings. Locally, healthcare practices are beginning to screen patients for food insecurity, and workgroup members identified a need to share lessons learned, best practices, and the wealth of local resources and innovative programs available in our community. This report provides healthcare providers with information on how to screen and respond to food insecurity, including an extensive list of local resources. The report also highlights the need for more research on how to most effectively screen and respond to food insecurity and to study the link between food insecurity screening and patient health outcomes. Healthcare providers have the opportunity to screen and identify food insecure patients and connect them with resources to alleviate hunger, reduce food insecurity, and improve health. We recommend adopting the following steps in screening for food insecurity. Obtain organizational buy-in and identify a champion Prior to screening for food insecurity, providers should obtain buy-in from leadership in the organization and identify a staff member that is willing to champion the issue. An organizational champion will be able to help with training, implementation, evaluation, and quality improvement projects. Select a screening tool There are several validated survey tools that screen for food insecurity. The most widely adopted screening tool is the Hunger Vital Sign, a two-question screen developed and validated by Hager et al. Develop a workflow Practices will need to develop a workflow for food insecurity screening. Practices should consider whether to use verbal, electronic, or paper screens. Practices also need to consider their patient population and which patients to screen; staff and patient comfort level and who should conduct the screening; and when and where to screen. Practices should adopt processes that will easily fit into their existing workflow. Documentation and embedding the food insecurity questions into the electronic medical record It is important to document the results of the food insecurity screen as part of the patient s medical record. Embedding food insecurity questions into the EMR will make screening for food insecurity and tracking progress easier. Staff training and patient communication Staff training on food insecurity, the use of the screening tools, documentation, and sensitive communication is essential. Patients and providers may be uncomfortable discussing food insecurity so practices should take steps to create an environment where patients and providers are able to comfortably discuss food insecurity. Respond to a positive screen If a patient screens positive for food insecurity, providers should connect the patient to resources, which may include referrals to enroll in federal nutrition programs, referrals to local food pantries and food programs, offering interventions that address food insecurity, and connecting patients with other community resources. Appendix A includes a list of programs including: local resources, federal nutrition programs, national resources, and programs specific for food insecure children and seniors. Develop partnerships with local resources and food programs The quality and capacity of local pantries varies tremendously. Creating partnerships with pantries and food programs assists healthcare providers in 5

6 offering referrals to programs and resources that are most beneficial to the patient. It also allows practices to collaborate with community organizations to track referrals and develop programs that promote healthy eating. Focus on health and nutritious foods When possible, providers should focus their food insecurity efforts on not only alleviating immediate hunger, but also improving long-term health. Providers should prioritize pantries and resources that offer healthy high-quality foods and consider participating in programs that promote healthy eating such as food prescription programs. Address root causes of food insecurity and other social determinants of health Typically food insecurity is not an isolated issue for families and is linked to other social needs. Efforts to alleviate food insecurity may be more successful if they incorporate strategies to address the underlying causes of food insecurity. Get involved Participate in local, state, and national organizations that are addressing food insecurity. Advocate for local, state, and national policies that will help patients access affordable and nutritious food and address underlying causes of food insecurity. Evaluate While research has demonstrated the connection between food insecurity and poor health, food insecurity screening has outpaced evaluation and research. More research and data is needed to understand the impact of food insecurity screening on health outcomes and food insecurity levels. Additional research and evaluation is needed to identify the best way to screen and follow-up on a positive screen. 6

7 INTRODUCTION Food insecurity is a pressing public health issue that impacts the lives of millions of Americans every year. According to the U.S. Department of Agriculture (USDA), 15.6 million (12.3%) households in the U.S. were food insecure at some point in The USDA defines food insecurity as the limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways. 2,3 A household is food insecure not only if there are disrupted eating patterns present, but also if there is a reduction in quality, variety, or desirability of diet. 2 Food insecurity should be seen as a household-level economic and social condition of limited or uncertain access to adequate food. 4 Food insecurity is prevalent locally and across the state of Texas. According to Feeding America, 15.7% of Texans are estimated to be food insecure. 5 There are an estimated 724,750 food insecure individuals in Harris County with a food insecurity rate of 16.6%. Among children in Harris County, the food insecurity rate is 23.6%. 6 Research across the lifespan indicates that food insecurity has significant and sometimes differing impact on individuals as they age. Children living with food insecurity are more likely to have asthma, iron-deficiency anemia, behavioral disorders, and cognitive impairment. 7 Pregnant women also are at greater risk for iron-deficiency anemia as well as excess weight gain, anxiety, and depression. Pregnant women are also more likely to birth smaller, sicker infants. 8 Adults impacted by food insecurity are more likely to be diagnosed with diabetes and hypertension, and report more mental health problems. Food insecure seniors are less likely to live independently as they age. Food insecurity typically does not occur in isolation and is connected to other social determinants of health. Families without sufficient income are routinely faced with difficult decisions on how to use their limited income between food, medical bills, prescriptions, utilities, transportation, and housing. In fact, 34% of families who identify as food insecure reported having to choose between paying for food, medicine, or medical care. 9 Furthermore, grocery stores and vendors that sell healthy foods are more likely to be located in affluent neighborhoods, making access to healthy foods much more difficult in low income neighborhoods. 10 Low resource neighborhoods have increased availability of fast food restaurants that offer energy-dense, nutrientpoor foods. 10 Certain populations are at greater risk for experiencing food insecurity, including families headed by single women, children in immigrant families, families with less education, and families experiencing separation or divorce. 11,12 BACKGROUND The Section of Public Health Pediatrics at Texas Children s Hospital facilitates Adverse Childhood Experience (ACE) Workgroups to address gaps in knowledge and practice to mitigate childhood adversity, foster resilience, and improve outcomes for children and families. The ACE workgroups are a collaboration of healthcare, academia, local government, and community organizations. In early 2017, an ACE workgroup was formed to address food insecurity screening in healthcare settings. This resource guide was developed by clinicians, members of local nonprofits, government agencies, academics, and other public health professionals with experience in food insecurity. The goals of this report are to: 1. Provide local healthcare professionals with practical advice on how to screen for food insecurity and how to respond to a positive screen 2. Identify local food programs and resources 3. Highlight opportunities for more research on how to most effectively screen and respond to food insecurity and to study the link between food insecurity screening and patient health outcomes. 7

8 SCREENING FOR FOOD INSECURITY Healthcare providers have a unique opportunity to screen patients for food insecurity and to refer and connect patients experiencing food insecurity to appropriate resources. Major medical organizations, including the American Academy of Pediatrics (AAP), recommend that healthcare providers screen patients for food insecurity. 13 Short validated screening tools exist, and providers across the region and nation are adding screening to their practice and work flow. Urban practices have seen positive food insecurity screen rates of 20% 14 while suburban practices have seen rates ranging from 1-6%. 15 Locally, Memorial Hermann has observed 27% of patients screening positive in their emergency rooms, 30% in school based clinics, and 15% in neighborhood clinics. 16 Food insecurity is often seen as a symptom of poverty. Some would argue that screening for food insecurity and providing a referral to food sources without addressing underlying causes such as poverty, employment, living wages, and transportation--is not an effective response to address food insecurity. Others would argue that screening for food insecurity and referring patients to food resources both is helpful in addressing the immediate food insecurity as well as improving patient-provider communication in addressing health concerns and compliance with treatment and interventions. 17,18 As providers consider incorporating food insecurity screening into their practice and work flow, it is important to consider food insecurity as it relates to both hunger and health. Is the practice trying to alleviate hunger or is the practice trying to support healthy eating and better health? The appropriate follow-up and intervention will vary depending on if the goal of the screening is to alleviate hunger or to improve health. In addition to the information provided in this resource guide, the AAP and American Association of Retired People (AARP) have published toolkits on screening for food insecurity which may be useful for healthcare providers that serve pediatric and older patient populations. 19,20 The AAP has published Addressing Food Insecurity: A Toolkit for Pediatricians and the AARP has published Implementing Food Security Screening and Referral for Older Patients in Primary Care. 8

9 INTEGRATING FOOD INSECURITY SCREENING INTO YOUR HEALTH CARE PRACTICE Many health care providers in Houston and Harris County have begun to screen for food insecurity. The following steps are helpful in preparing to screen for food insecurity. Leadership and staff buy-in Identifying an organizational champion Selecting a screening tool Forming community partnerships Staff training Patient community and sensitivity Developing a workflow Documentation Responding to a positive screen Leadership and staff buy-in For successful implementation of food insecurity screening in the outpatient setting, it is important to begin by obtaining the support of the administrative and leadership team. Discussions should begin with clinic directors and practice managers, and additional conversations should occur with providers and staff who will be conducting food insecurity screening. For practices that are part of larger organizations and/ or academic or governmental institutions, it may be necessary to obtain approval from those in higher leadership positions. Those preparing to implement programs to address food insecurity should take into consideration that this process could be lengthy. Once leadership support is obtained, the next steps involve discussions with those who will be carrying out the screening, including front desk clerks, medical assistants, nursing staff, healthcare providers, social workers, or other ancillary staff. It is recommended that each practice should implement screening in a way that best fits with the existing work flow. Identifying an organizational champion In addition to obtaining buy-in from leadership and clinic staff, it is helpful to identify and assign a provider champion. A provider champion can assist with staff training, developing community partnerships, implementation, tracking screening rates, quality improvement initiatives, and long-term sustainability. Organizational champions are also able to monitor and track screening and referral processes to assess if they are being implemented as planned. Selecting a screening tool There are several validated screening tools that are used to screen for food insecurity. The most widely adopted screening is the Hunger Vital Sign, a two-question screen developed and validated by Hager et al Within the past 12 months, you worried that your food would run out before you got money to buy more. Often true Sometimes true Never true 2. Within the past 12 months, the food you bought just didn t last and you didn t have money to get more. Often true Sometimes true Never true A response of sometimes true or often true to either question is considered a positive screen. However, a patient and his or her family may still be in need of food assistance if they respond never true. Patients may be embarrassed to respond affirmatively, and the tool does not detect differences in how different household members are impacted by food insecurity. The two-question screen was adopted from the USDA s 18-question Household Food Security Scale, which is currently considered the gold standard for screening for food insecurity. Many clinical settings have opted for the two-question screen as it takes less time and has a high validity. The 18-question screening tool is available on the USDA s Survey Tools website at: In addition to the food insecurity screening tools, there are several screening tools that screen for a variety of social determinants of health, including food insecurity. Should providers want to explore other aspects of the patient s living conditions or some of the underlying causes of food insecurity, there are established screening tools including: Accountable Health Communities Social Needs Screening Questions 22 I HELLP (Income, Housing/utilities, Education, Legal status, Literacy, Personal safety) 23 9

10 PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences) 24 SEEK (Safe Environment for Every Kid) 25 WE CARE (Well-child care Evaluation Community resources Advocacy Referral Education) 14 Becoming familiar with local resources will enable providers to make better referrals that fit the needs of their patients. FORMING COMMUNITY PARTNERSHIP Prior to screening for food insecurity, it is necessary for practices to understand the resources available in the community. The quality and capacity of food pantries varies dramatically and may influence referrals. For example, on one end of the spectrum, pantries may only be open a couple times a month and the food available may be limited to donations and non-perishable items. On the other end of the spectrum, there are food pantries that stock fresh produce from urban farms, offer nutrition education, incentivize selecting healthy foods, and provide a grocery store atmosphere. interest and ability to track referrals they receive from a healthcare provider and share that information with the healthcare provider in order to track referral utilization among the positively screened patients. Providers or other members of the practice team such as the organizational champion should call and, if possible, visit nearby pantries. The quality and capacity of pantries varies greatly in our region. When meeting with the pantry here are some questions to consider asking: 1. When are you open? 2. What are your eligibility requirements and what documentation is needed to show eligibility? 3. How often can an individual come to get food? 4. Do you give prepared bags of food to your clients or are they able to choose their own foods? If a practice is interested in improving health in addition to alleviating immediate food insecurity, providers may consider also asking: 5. Does your pantry have any programs or initiatives to promote healthy eating? 6. I have many patients with diabetes. Do you have the capacity to partner with our clinic to offer more foods that fit a diabetic s nutritional needs? 7. Our clinic is interested in tracking referrals to your pantry. Do you have the capacity and would you be interested in helping us track referrals? 8. Our clinic is interested in writing food prescriptions to your pantry that specify certain food and food groups. Do you have the ability to modify the foods you offer and would you be interested in partnering with us? Becoming familiar with local resources will enable practices to make better referrals that fit the needs of patients and the practice s goals for food insecurity screening. This information can be pulled together into a resource sheet for patients. Furthermore, pantries have varied capacity and interest in creating partnerships to not only address the hunger of clients, but also their health. For example, some of the pantries expressed a willingness and the ability to modify the available food in the pantry to align with the neighboring healthcare institution s recommendations and referrals. In addition, some pantries expressed an 10

11 Staff training Appropriate staff training on food insecurity, the use of the screening tool, documentation, and sensitive communication is essential. Practices should consider that staff members may initially be uncomfortable speaking to patients about food insecurity. Incorporating role playing into a training so staff members can practice asking about food insecurity may be helpful to some providers. In addition, practices can develop sample scripts for providers to use. Re-educating staff at regular intervals is a good reminder of the importance of the process. Highlighting data from the previous quarter can be utilized as a motivational method for engaging staff members. Additionally, as new staff members are brought onboard, appropriate training needs to be a part of their orientation pathway. The Houston Food Bank provides food insecurity trainings for health professionals. The training content includes food insecurity, the intersections between health and hunger, screening, interventions, and the resources available at the Houston Food Bank. For those interested in receiving a training, please the Houston Food Bank s Nutrition Education program at nutrition@houstonfoodbank.org. PATIENT COMMUNICATION AND SENSITIVITY Patients and providers may be uncomfortable discussing food insecurity, so practices should take steps to create an environment where patients and providers are able to comfortably discuss this issue. All patients should be screened for food insecurity to avoid singling out patients and making incorrect assumptions about patients and families in need. If a practice is using a verbal screen, providers may want to begin with an icebreaker to make patients feel more comfortable disclosing food insecurity. For example, We know that food insecurity is a concern for many of our families and we are now asking everyone about problems with having enough food at home. Alternatively, Food and nutrition plays such an important role in the health of our patients so we are now asking all of our patients about having enough food at home. Focusing on the link between food and health may help staff feel more comfortable in discussing the subject matter with patients. After a positive screen, providers can open up a discussion on food access by asking questions that link food and health such as: Do you often feel tired or seem to have low energy throughout the day? Do you eat breakfast? What do you typically eat for breakfast? How many meals do you eat in a given day? Do you believe that the foods you typically eat give you a sufficient amount of energy to get through the day? What are these foods? What types of foods do you or your family enjoy? How many home cooked meals are prepared in your household? In addition, posters and information about food insecurity and nutrition assistance programs can be placed prominently in the clinic so that the subject matter is easier to address. Asking individuals and families about their food security is very personal and providers should speak with patients privately. For example, some parents try to hide their challenges with getting enough food from their children. If the patient is a child and you are speaking with the parent, remember to make the connection between food and behavioral outcomes for children: How are your children doing in school? Have you noticed any behavioral changes or difficulties? Do your children have difficulty concentrating on tasks? What do your children typically have for breakfast? Lunch? Dinner? Do your children have healthy appetites? What are their favorite foods? What are their least favorite foods? 11

12 DEVELOPING A WORK FLOW Practices will need to develop a workflow for food insecurity screening based upon their patient population, practice flow, resources, and to minimize staff burden. PAPER, ELECTRONIC, AND VERBAL FORMAT Practices can use paper, electronic, or verbal formats to screen for food insecurity. Paper screens: Paper screens can be administered along with other questionnaires and be addressed only if positive, saving the provider time in their patient encounter. Staff or providers who feel uncomfortable asking patients about this topic may prefer paper questionnaires. In addition, some patients may be more willing to disclose sensitive topics like food insecurity on paper or electronically as opposed to verbally. 29 For pediatric populations, parents may feel uncomfortable admitting to food insecurity problems in front of children. Parents may be more inclined to respond honestly on paper. Literacy and language barriers may be obstacles to utilizing this method and affect accuracy. Efforts should be made to have paper screens available in languages prominent in the community being served. Electronic screens: Electronic versions of food insecurity screening questionnaires should be considered by practices that have the capability or those using electronic medical records (EMR). Having patients complete the screening questions on a tablet, smart phone, or other electronic device that inputs information directly into the EMR could be helpful. If the practice already uses other electronic questionnaires, then food insecurity screening could be added to the workflow easily without increasing intake time. Electronic documentation could also assist with better tracking of food insecurity screening data for quality improvement or research purposes. Verbal screens: Some families who have developed trust with their providers may be more open to talking about food insecurity than answering a paper questionnaire. Providers who have a strong relationship with their patients may feel that asking verbally is more fruitful. In addition, low literacy levels can affect the accuracy of a paper or electronic screening questionnaire. Verbal screens may be a better option if literacy levels are a concern. WHO, WHEN, AND WHERE TO SCREEN FOR FOOD INSECURITY Clinical sites must decide whom, when, and where to screen for food insecurity. Who should conduct the screening: Practices utilize different team members to conduct the screen, including: medical assistants, nursing staff, physicians, or as part of the intake form. In addition, some practices utilize a team approach such as nursing staff administering the screen and the social work staff responding to a positive screen and providing resources. When screening should occur: It is recommended that patients be screened during new patient visits and annual physicals or wellness visits. Additionally, any patient who is considered high risk should also be screened. For example, the AAP policy statement on addressing food insecurity in children recommends screening at scheduled health maintenance visits or sooner, if indicated. 13 High risk populations include: families with children, uninsured patients, those expressing other financial hardships, immigrant populations, racial and ethnic minorities etc. 30 In addition to the primary care setting, other settings such as emergency centers and drop-in clinics may be interested in screening for food insecurity. Who should be screened: As a general rule, patients should be screened directly. When caring for pediatric populations, parents are typically screened. However, consideration may be given to screening older children and adolescents directly (see section on special populations). In addition, caregivers of elderly patients could also be considered for screening. 12

13 Where should screening occur: Food security is a personal issue. Patients should be screened in private away from other patients and family members. DOCUMENTATION WITH AND WITHOUT AN ELECTRONIC MEDICAL RECORD Once food insecurity screening has been completed, it is important to document the results as part of the medical record. How each practice documents food insecurity screening will vary and depend on its use of EMRs. One option is for medical assistants (or other designated health care provider) to review screening results and assume responsibility for documenting the information in the patient s chart. Designating someone other than the physician or provider to document the screening results decreases the burden on the medical provider. Providers can use one of the following diagnoses codes for positive screens: ICD-10-CM Diagnosis Code Z59.4 (lack of adequate food and safe drinking water / food insecurity) or ICD-10-CM Diagnosis Code Z59.5 (extreme poverty) and add this information to the patient s problem list. Including food insecurity results as part of the medical record provides information to health care providers about an important condition that can affect the patient s current treatment plan and their long-term care. Providers may ask additional questions to patients with food insecurity to target these concerns and help provide better care and appropriate treatment plans. Tracking food insecurity over time helps identify whether the patient s needs are acute or chronic, and allows clinicians to monitor if prior referrals are improving the patient s situation. For clinical sites that use EMRs, it is helpful to engage and work with information technology (IT) to develop potential EMR solutions for documenting food insecurity screening results. IT can also develop applications to document food insecurity in a searchable field of the medical record so that providers can easily track food insecurity over time for individual patients and for population health management. Similarly, IT may be able to help embed resource sheets into the EMR, create prompts to remind providers to conduct and review the screening, and flag records when there is a positive screen. Providers should keep in mind that changes to the EMR typically take time. While EMR improvements are under development, providers should develop a process for food insecurity screening, documentation, and referrals that is feasible within their current system. Practices that do not use EMR should consider including food insecurity screening on their paper templates to ensure responses are reviewed, positive screens are addressed appropriately, and screening data can be tracked over time. Responding to a positive screen A recent study identified that the primary barriers to physicians screening for food insecurity include uncertainty about how to handle a positive screen and lack of knowledge of community resources. 31 Once a patient is identified as food insecure, referrals should be made to assist with access to food, which may include: federal food assistance programs such as Supplemental Nutrition Assistance Program (SNAP); Women, Infants and Children (WIC); Temporary Assistance for Needy Families (TANF); National School Lunch Program; and Summer Food Service Programs. Referrals may also include information about local food pantries and local programs providing food assistance. Detailed information on how to respond to a positive screen is included in the next section. Social work teams, case managers, or community health workers can assist with developing a list of resources available in the community the practice serves and helping patients enroll in food assistance programs. Health educators, dieticians, nurses, medical assistants, or physicians may be responsible for responding to a positive screen as well. 13

14 Developing strong partnerships with these community organizations can also help develop more robust referral systems and sustain the screening process long term. Interventions like food scholarship or food prescription programs are becoming more common across the United States. Other social needs should also be considered along with the possibility that families may need referrals to other social assistance programs. as other interventions may take several weeks to enroll. Similarly, if a patient has diabetes, they should be referred to a program that offers foods that are compliant with a diabetic diet. Just as it is important to document food insecurity screening in the medical record, it is important to document what interventions have been provided to the patient. Resource lists can also be embedded into the EMR for easy access. Ideally, the referral would be an automated process in the EMR. In this scenario, if a certain ICD-10 code is used, a list of resources would automatically be added to the patient instructions in the EMR or a referral to a local community partner would automatically be placed. When sharing information with community partners, health systems must act in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Providers must obtain consent from patients prior to providing their basic information (name, number, address) to local resources as part of the referral processes. INTERVENTIONS AND RESOURCES There are many programs and resources available in Houston and Harris County to support food insecure families. Providers can respond to a positive screen by: Referring patients to enroll in federal nutrition programs such as SNAP, WIC, and the National School Lunch Program; Referring patients to a local food pantry and food programs; Offering interventions that address food insecurity; and Connecting patients with other community resources. Clinicians should carefully consider the needs of a patient when responding to a positive screen for food insecurity. For example, if a patient and his or her family are hungry and do not have money for food, they should be referred to an emergency food pantry Federal nutrition programs Houston and Harris County residents have access to several federal nutrition programs that provide eligible participants access to supplemental food and other resources. These programs include SNAP, TANF, WIC, the National School Lunch Program, the School Breakfast Program, and the Summer Food Service Program. For more detailed information on the federal nutrition programs, see Appendix A. Participation in federal nutrition programs has been shown to improve nutrition and lessen food insecurity in individuals and families. 32,33 In addition, these programs assist households in being able to redistribute income that would have otherwise been used to purchase food. These programs connect families with continual access to food, but enrollment can take several weeks and they have varying eligibility requirements. Pantries and food programs In addition to the federal nutrition programs, there are numerous food pantries and food programs in Houston and Harris County to support food insecure families. The Houston Food Bank maintains an interactive online database and map of most of the food pantries in Houston and Harris County. 14

15 Providers can enter their zip code for a list of nearby pantries. The database is accessible at In addition, the University of Texas School of Public Health hosts an interactive map of the various food access related services in Houston and Harris County. The interactive map is available at edu/research/centers/dell/houston-area-food-accessanalysis-tool/ also maintains a list of food pantries in the greater Houston region is a helpline run by the United Way of Greater Houston that connects residents in Greater Houston with social services. Providers can either call or go to referral. unitedwayhouston.org to search for food programs and food pantries. Food pantries and programs are listed under basic needs. In addition to the local food pantries, there are numerous food programs and resources that address food insecurity. 34 A list of some of these programs is available in Appendix A. Interventions that address food insecurity In addition to referring patients to pantries and federal nutrition programs, many healthcare providers are participating in innovative programs to address food insecurity. Food prescriptions: In food prescription programs, physicians write a prescription for nutritious food to be redeemed at a local pantry that is partnering with the clinic. Food pharmacies: Similar to food prescription programs, patients can access a food pharmacy with a prescription from their physician. Food pharmacies are similar to pantries, but typically they only offer healthy food, are located on-site or near hospitals and clinics, and a prescription is needed to receive food. Onsite enrollment to federal nutrition programs: Some patients may find it difficult to enroll in federal nutrition programs. As a result, instead of referring a patient to enroll in a federal nutrition program, some clinics assist patients in enrolling in these programs. Often, social workers or community partners will help the patients with enrollment. Onsite food pantries or food distribution sites: Clinics can choose to operate or partner with local pantries to distribute food onsite to food insecure families. Patient education: In addition to connecting patients with food resources, providers are also educating patients on the connection between food and health and the importance of choosing nutritious foods. Connecting patients with other community resources Typically, food insecurity does not occur in isolation, and often families that screen positive for food insecurity would benefit from additional programs and interventions. After a positive screen for food insecurity, providers may consider speaking with or screening the patient for additional social needs and connecting the patient with appropriate resources. Harris County Public Health has developed a guide, Pathway: A Guide to Clinical Screening for Social Determinants of Health, to encourage and support organizations, physicians, and others to begin screening for SDHs. It also contains more specific recommendations on SDH screening implementation, practice, and screening tools can also help providers identify additional resources. Disaster resources Additional resources may be available to residents after disasters, such as hurricanes. For example, Disaster Supplemental Nutrition Assistance Program (D-SNAP) offers short-term food assistance benefits to families recovering from a disaster. 35 Beneficiaries receive up to two months of food within 3 days of applying. In addition, the Houston Food Bank works with nonprofits across the region to set up temporary pantries to increase the availability and accessibility of food after a disaster. See Appendix A for additional information. 15

16 LOCAL SPOTLIGHTS There are numerous innovative initiatives in Houston and Harris County that are addressing food insecurity. Centering Pregnancy Centering Pregnancy is partnering with the Houston Food Bank to increase fruit and vegetable intake, encourage healthier eating habits, and provide extra incentives for attendance at prenatal care visits to low income pregnant women. Centering Pregnancy is a model for providing prenatal care to groups of women in 10 two-hour sessions of interactive activities. To address good nutrition, the program provides fresh produce (~30 pounds per person per session) as well as shelf-stable high protein items to women who attend the groups. This model is currently being evaluated to assess food insecurity and the impact of providing fresh and high protein food within a clinical setting. Harris County BUILD Health Partnership: 36 The Harris County BUILD Health Partnership created Harris County s first formal Food Prescription (Rx) Program to address food insecurity in the city of Pasadena. In the BUILD model, participating healthcare providers enroll patients who screen positive for food insecurity (using the USDA 2-question food insecurity screener) into the BUILD Food Rx Program where they receive a sixmonth prescription for pounds of fruits and vegetables every two weeks. The Rx also includes two BUILD-Friendly items per redemption (i.e., lean proteins and dairy, legumes, etc. that could help constitute a complete meal), along with healthy recipes, and a Brighter Bites nutrition education handbook. All prescriptions are filled at a central BUILD-only Food FARMacy hosted in a dedicated space in a local food pantry sourced by the Houston Food Bank. All food is free to enrolled participants, and no return visits to the healthcare providers are required. During the program s first/pilot year (2017), participating healthcare providers included two school-based wellness centers, an FQHC, and a bariatric practice. Evaluation of the pilot showed a 95% decrease in food insecurity across all participants (n=174). The cost of the program was about $12 per participant per redemption. The sustainability of the BUILD Food Rx Program depends on direct funds in order to support the FARMacy component. Efforts to raise or re-allocate funds for the program are ongoing. As of the date of this document, funding has been identified to conduct a second year of the program beginning in 2018 at four healthcare provider locations in Pasadena. Houston/Harris County Patient Food Insecurity and Healthy Eating Asset Map: Clinton Health Matters Initiative (CHMI) and General Electric (GE) Healthymagination are leading an effort across Houston and Harris County to encourage and support medical providers to screen for food insecurity. The purpose of these efforts is to identify the magnitude of food insecurity in the community, prioritize the areas for immediate intervention, create a plan to initially address the highest priority needs, and implement a community wide roll-out in as timely a manner as possible. The food insecurity effort aims to serve as a foundation and model to incorporate additional social aspects of patients health such as depression, stress, substance use, living conditions, literacy, safety, transportation, and economics. In addition, GE and CHMI in partnership with The University of Texas School of Public Health are building an open source asset map, which will 16

17 serve the community by providing locations, hours of operation, and resources available for food and hunger resource locations. The objective is to provide a web portal accessible by both healthcare providers and members of the community who would benefit from access to additional food resources. The asset map is available at research/centers/dell/houston-area-food-accessanalysis-tool/ Legacy Community Health and Social Determinants of Health: Legacy Community Health is piloting a program that will address patients social determinants of health, including food insecurity. Using a model designed by Health Leads, Legacy is building and integrating programming that addresses all patients basic resource needs as a standard part of medical practice. The pilot will connect patients to community-based resources that can improve their social determinants of health. This programming goes beyond basic screening and resource referral. Using the Health Leads model, trained volunteer health advocates will provide intensive client follow-up to ensure patients are referred to the correct resources and that patients are able to utilize the resources. Legacy will also utilize a digital platform designed by Health Leads that can track the appropriateness of referrals based on feedback from the health advocate and patients. The pilot is set to begin in early Memorial Hermann Health System: In 2016, the Memorial Hermann Community Benefit Corporation launched an initiative to screen patients for food insecurity. The screening has been implemented throughout Memorial Hermann s hospitals, school-based health centers, neighborhood health centers, and the Memorial Hermann Medical Group. Since then, Memorial Hermann s school-based health centers have been a collaborative partner with the Houston Food Bank s Scholarship Pantry at Sharpstown High School, the BUILD Health Challenge food prescription (FVRx) program in North Pasadena, and Wholesome Wave s Fruit and Vegetable Prescription Program throughout the Houston region. An upcoming food security collaborative involves Harris County Public Health and the Houston Food Bank bringing a mobile nutrition food truck to lowincome, low food access, and low transportation access unincorporated areas outside of the city of Houston. Each venture includes nutritional guidance by registered dietitians and measurable outcome data on changed behavior patterns to support the work. SNAP Access at Houston Farmers Markets: The City of Houston Health Department, in partnership with the Houston Food Policy Workgroup, provides technical assistance and education to farmers markets that are interested in becoming SNAP-authorized. This allows SNAP recipients to use their SNAP benefits to purchase food at farmers markets. The farmers markets offer fresh, healthy fruits and vegetables from local producers. A list of farmers markets that currently accept SNAP/EBT is listed in Appendix A. In addition, several markets host the Farmers Market Nutrition Program (FMNP), which provides $30 worth of vouchers to eligible families that can be used to purchase fresh fruits and vegetables from select farmers markets. COLLECTING DATA AND EVALUATION Evaluating a food insecurity screening program allows practices to measure the effectiveness of the program. It also helps practices identify opportunities to improve the program. There are several options on collecting data and evaluating the effectiveness of screening for food insecurity. Tracking the number and percent of eligible patients who are screened for food insecurity. This will allow practices to identify if screening rates are lower than desired. To address low screening rates, practices can host follow-up training with staff or identify challenges and solutions that are preventing clinic staff from completing the screen. 17

18 Tracking the completed food screens can be done quickly if the screen is entered into an EMR. If the screen is not entered in an EMR, though time consuming, rates can be calculated through manual chart reviews. Tracking the number and percent of patients that screen positive. This allows practices to better understand their patient population. In addition, if the rate of positive screens is lower than expected, a practice may want to review their screening protocol to see if it is conducive to patients disclosing private information such as food insecurity. Quality improvement methods can be used to improve identification of household food insecurity. 37 food insecurity, such as rates of obesity, percent of families having to choose between medical bills and food, compliance with medical treatment, healthcare utilization, etc. Studies have been published on the feasibility and acceptability of food insecurity screening, but more research is needed to demonstrate if screening for food insecurity leads to improved outcomes for patients. 38 Tracking the number and percent of patients that access services. There are concerns that patients who are referred to social services don t always access the services. Tracking the number of patients that actually access the services can help practices improve their screening protocol. Practices can work with community partners to develop a tracking system. For example, if a provider gives a patient a food prescription, the food pantries can collect the food prescriptions to identify how many patients are accessing the resources they are referred to. Alternatively, practices can directly follow-up with patients through phone calls, surveys, or speaking with them at follow-up appointments to see if the patient accessed any of the services to which they were referred. Tracking food insecurity and health outcomes. In addition to tracking screening rates and accessing referrals, more comprehensive evaluations and research can measure if the screening and referrals improve outcomes for patients. Comprehensive evaluations and research are often time consuming, but provide critical information on the utility of food insecurity screening and identify best practices so health care providers are able to screen and respond in a manner that is most likely to improve outcomes for their patient and their patient s family. For example, a health care provider may want to screen the patient for food insecurity at a follow-up visit to see if fewer families are food insecure after referral to resources. In addition, providers could also look at other outcomes that are associated with 18

19 SUSTAINABILITY: FUNDING FOOD INSECURITY SCREENING AND REFERRAL PROGRAMS Many local healthcare organizations have prioritized the importance of food insecurity screening and have integrated screening and referrals into their practice without external funding. However, others have used external funding sources to integrate screening, improve local food pantry offerings, and to study the effectiveness of screening. Food insecurity screening programs across the country are utilizing the following resources to fund food insecurity screening and referral programs: 39 Medicaid fee for service such as billing codes for planned pediatric obesity visits State Medicaid waivers Health plans and Medicaid managed care organizations Federal grants City, county, and state health departments Community benefits departments at hospital systems Corporate food or health care companies Local, state, and national foundations State departments of agriculture Currently, Medicaid and private health insurance companies do not reimburse providers for routine screening of food insecurity. However, the Centers for Medicare and Medicaid Services (CMS) is currently piloting if screening for social determinants of health, including food insecurity, and referring patients to community resources decreases rates of emergency room utilization. If the outcomes of these studies are favorable, there may be more opportunities to be reimbursed for screening for food insecurity in the future. LIMITATIONS Food insecurity screening and referral provides a great opportunity for healthcare providers to address root causes of health. However, screening for food insecurity in the clinical setting is fairly new, and evaluation and research is lagging behind the uptake of food insecurity screening. More studies are needed to understand the outcomes of food insecurity screening, how to most effectively screen patients, the most effective referrals and interventions, and the impact of food insecurity on patients health. Screening limitations: The Hager et al. study published in 2010 showed that utilizing the two-question food insecurity screening instead of the full 18-item USDA screening tool has 97% sensitivity and 81% specificity. 21 However, several questions arise in regards to time frame of the screen. The hunger vital sign asks about hunger over the past 12 months, as opposed to other available questionnaires that ask about hunger in the past three months. Families may not disclose food insecurity that occurred one year ago if it is improving. 21 Secondly, the USDA 18-question tool was utilized to measure household level food insecurity rather than individual level food insecurity. If, for example, a child lives in multiple households due to parental separation, then there could be differing levels of food insecurity. In addition, the Hunger Vital Sign does not measure the quality of food that someone is accessing. It also does not measure community level access to food such as grocery stores versus corner stores. 40 These factors also impact health; access to quality food is key in order to improve health. Houston and Harris County is one of the most diverse areas in the United States and is home to people speaking many different languages. Currently, the food insecurity tool is only validated in English and in Spanish. 41 Clinics can use translators to ask the screening questions to patients speaking another language, but this method has not been validated. Responding to a positive screen After identifying a food insecure patient, a clinic should respond to the positive screen. However, there is no standard of care for responding to a positive screen. There is substantial variability in how practices respond to positive screens, resulting in challenges in understanding the impact and 19

20 effectiveness of screening for food insecurity. As previously mentioned, research and evaluation has not kept up with the uptake of screening for food insecurity, and more research is needed to identify best practices and the impact of screening for food insecurity on food security and health. Many of the pantries and local food programs have limited capacity, which may inhibit a family s ability to access enough nutrition to meet the family s food needs. Contributing factors include limited staff and volunteers, hours open, food resources, and narrow eligibility requirements. These requirements may include restricted zip codes, number of visits per month, immigration status, and family income. Furthermore, the quality of the available food varies greatly in pantries. Some pantries rely on food donations while other pantries purchase food from grocers and the Houston Food Bank. Some pantries have fresh produce and healthy options, while other pantries have a limited supply of healthy food. This can be especially problematic for patients with diabetes and other chronic diseases. Providers are encouraged to visit local pantries to better understand their capacity to meet the needs of the clinic s patients. SPECIAL POPULATIONS AND CONSIDERATIONS Providers should be aware of the needs of their patient population. Diabetes and Chronic Disease: For a diabetic or any chronic disease population, special care should be given to offer programming that provides the food insecure patient with access to healthy foods that meet their nutritional needs. Ideally, patients with diabetes and chronic diseases would be referred to food programs and pantries that have designated resources, programs, and foods that are tailored to the needs of the patient population. In some studies, patients with diabetes had a higher prevalence of food insecurity than patients without diabetes. 42 Children: Children should not be asked the food insecurity screening questions. In fact, out of courtesy to all patient populations, parents with children should be asked the questions discretely or in a written form. In addition, many of the local food programs are grant funded and while beneficial during the duration of the program, families may return to their prior level of food insecurity after completion of the program. Provider s time In a busy clinical practice, a provider s time is often limited and there are other competing screenings that also need to be addressed. For example, within the pediatric clinical setting screening for food insecurity may be competing with screening for developmental issues, lead screening, obesity etc. Clinics must look at their workflow to see how food insecurity screening can be implemented in an efficient manner. Follow-up and tracking data There are some innovative programs to track referrals to food programs, but following up with patients and tracking referrals can be time consuming and challenging for clinical practices. Adolescents: The USDA offers a nine-question Self-Administered Food Security Survey Module for Youth Ages 12 and Older if a healthcare setting is interested in screening adolescents. 43 Internal validity of the module was found to be adequate for children ages 12 and older, but its use is not recommended for younger children. Cognitive testing indicated that recall and responses for a 12-month period might not be reliable, and a 30-day reference period is recommended for youth ages 12 and older. The screener is available on the 20

21 USDA s Survey Tools website at gov/topics/food-nutrition-assistance/food-securityin-the-us/survey-tools/ Cultural sensitivity: Providers should be aware of the cultural practices of the populations they serve. Screening tools and resources should be available in the patient s preferred language. In addition, immigrant families are sometimes made up of members who are and are not U.S. citizens. Many times, even if immigrant status of household adults precludes them from programs, children are eligible and can be signed up for benefits. Having clinic staff, and in particular navigators and case managers up to date on eligibility standards for immigrant families, is helpful when making referrals in the community. Eligibility requirements vary greatly between the different food resources. In addition, when counseling patients on food, nutrition, and accessing resources, providers should be aware of different cultural food preferences. Low-literacy: Clinics should be prepared for patients with limited literacy skills. The food insecurity screening questions can be given verbally, but clinics should tailor the interventions and resource sheet to meet the literacy level and languages of the patient. RECOMMENDATIONS Food insecurity impacts thousands of people in our community and with a short screening tool, healthcare providers have the opportunity to identify food insecure patients and connect them with resources. Moving forward more research is needed to better understand why individuals are food insecure, how to prevent and respond to food insecurity, and how to mitigate the harmful effects of food insecurity. As we continue to expand our understanding of food insecurity and identify best practices, we recommend the following steps to address food insecurity in healthcare settings. 1. Obtain organizational buy-in and identify a champion. Prior to screening for food insecurity, providers should obtain buy-in from leadership in the organization and identify a staff member that is willing to champion the issue. An organizational champion will be able to help with training, implementation, evaluation, and quality improvement projects. 2. Develop partnerships with local resources. The quality and capacity of local pantries varies tremendously. Creating partnerships with pantries and food programs assists healthcare providers in both tracking referrals and enables providers to partner with pantries and programs that offer healthy food choices. 3. Embed the food insecurity questions into the electronic medical record. Embedding food insecurity questions into the EMR will make screening for food insecurity and tracking progress easier. The EMR can prompt healthcare providers to screen and more easily track screening rates and rates of food insecurity in the practice. 4. Connect food insecure patients with federal nutrition programs and local resources. After a patient screens positive, they should be connected with food programs. Federal nutrition programs provide more sustained food resources, and research studies have demonstrated that participation improves the nutrition of the participant and lessens food insecurity. 32,33 5. Focus on health and nutritious foods. When possible, providers should focus their food insecurity efforts on not only alleviating immediate hunger, but improving long term health. Providers should prioritize pantries that offer healthy high-quality foods and consider participating in programs that promote healthy eating, such as food prescription programs. 6. Evaluate. Currently, food insecurity screening has outpaced evaluation and research so there is insufficient data to support the best way to screen and follow-up from a positive screen. Healthcare practices should evaluate their food insecurity screening and follow-up in order to continually improve their practice and the health of their patients. 7. Address root causes of food insecurity and other social determinants of health, when possible. Typically food insecurity is not an isolated issue for families and is linked to other social needs. Efforts to alleviate food insecurity may be more successful if they incorporate strategies to address the underlying causes of food insecurity. 8. Get involved. Participate in local, state, and national organizations that are addressing food insecurity. Advocate for local, state, and national policies that will help patients access affordable and nutritious food. 21

22 REFERENCES 1. Food Security in the US - Key Statistics & Graphics. USDA Econ Res Serv usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-graphics.aspx. Accessed October 27, Food Security in the U.S. - Measurement. USDA Econ Res Serv topics/food-nutrition-assistance/food-security-in-the-us/measurement/. Accessed September 23, Andersen SA. Core indicators of nutritional state for difficult-to-sample populations. J Nutr. 1990; 120 Suppl: Food Security in the U.S. - Definitions of Food Security. USDA Econ Res Serv usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security/. Accessed September 23, Food Insecurity in Texas. Feeding America overall/texas. Accessed November 11, Gundersen C, Dewey A, Crumbaugh A, Kato M, Engelhard E. Map the Meal Gap 2017: Food Insecurity and Child Food Insecurity Estimates at the County Level.; Gundersen C, Ziliak JP. Food insecurity and health outcomes. Health Aff. 2015;34(11): Hilary Seligman MD MAS. Food Insecurity, Health, and Health Care resources/seligman_issues_brief_ pdf. Accessed September 23, Mabli J, Cohen R, Potter F, Zhao Z. Hunger in America 2010: National Report Prepared for Feeding America. Math Policy Res. 2010;2393(609):Mathemetica Reference No: Larson NI, Story MT, Nelson MC. Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med. 2009;36(1): Coleman-Jensen A, McFall W, Nord M. Food Insecurity in Households With Children: Prevalence, Severity, and Household Characteristics, USDA Econ Res Serv. 2013;(113). 12. Gundersen C. Food Insecurity Is an Ongoing National Concern. Adv Nutr. 2013;4(1): American Academy of Pediatrics. Promoting Food Security for All Children. Pediatrics. 2015;136(5):e1431-e Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing Social Determinants of Health at Well Child Care Visits: A Cluster RCT. Pediatrics. 2015;135(2):e296-e Palakshappa D, Vasan A, Khan S, Seifu L, Feudtner C, Fiks AG. Clinicians Perceptions of Screening for Food Insecurity in Suburban Pediatric Practice. Pediatrics. 2017;140(1): Nnake R. Personal communication. October 30, Roncarolo F, Bisset S, Potvin L. Short-term effects of traditional and alternative community interventions to address food insecurity. PLoS One. 2016;11(3). 18. Hendriks SL. The food security continuum: a novel tool for understanding food insecurity as a range of experiences. Food Secur. 2015;7(3): Addressing Food Insecurity : A Toolkit for Pediatricians. American Academy of Pediatrics Accessed November 27, Pooler J, Levin M, Hoffman V, Karva F, Lewin-Zwerdling A. Implementing Food Security Screening and Referral for Older Patients in Primary Care: A Resource Guide and Toolkit aarp.org/content/dam/aarp/aarp_foundation/2016-pdfs/foodsecurityscreening.pdf. Accessed November 27,

23 21. Hager ER, Quigg AM, Black MM, et al. Development and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity. Pediatrics. 2010;126(1):e26-e Billioux A, Verlander K, Anthony S, Alley D. Standardized Screening for Health-Related Social Needs in Clinical Settings - The Accountable Health Communities Screening Tool Kenyon C, Sandel M, Silverstein M, Shakir A, Zuckerman B. Revisiting the social history for child health. Pediatrics. 2007;120(3):e PRAPARE. National Association of Community Health Centers. Accessed September 23, The SEEK Parent Questionnaire. SEEK Child Abuse Prevention. Accessed September 23, Benefits of School Breakfast. Food Res Action Cent Accessed September 22, Jyoti DF, Frongillo E a, Jones SJ, Al JET. Community and International Nutrition Food Insecurity Affects School Children s Academic Performance, Weight Gain, and Social Skills. J Nutr. 2005;135(12): Whitaker RC, Phillips SM, Orzol SM. Food Insecurity and the Risks of Depression and Anxiety in Mothers and Behavior Problems in their Preschool-Aged Children. Pediatrics. 2006;118(3):e859-e Gottlieb L, Hessler D, Long D, Amaya A, Adler N. A Randomized Trial on Screening for Social Determinants of Health: the iscreen Study. Pediatrics. 2014;134(6):e1611-e Current and Prospective Scope of Hunger and Food Security in America: A Review of Current Research. RTI International report_final_ pdf. Accessed November 27, Barnidge E, LaBarge G, Krupsky K, Arthur J. Screening for Food Insecurity in Pediatric Clinical Settings: Opportunities and Barriers. J Community Health. 2017;42(1): Nord M. How much does the Supplemental Nutrition Assistance Program alleviate food insecurity? Evidence from recent programme leavers. Public Health Nutr. 2012;15(5): Ratcliffe C, McKernan S. How Much Does SNAP Reduce Food Insecurity? American Journal of Agriculture Economics. 2011;93(4). 34. Agency Locator. Houston Food Bank Accessed September 23, Disaster SNAP. Texas Health and Human Services. Accessed October 7, BUILD Health Challenge. Healthy Living Matters com/cms/one.aspx?portalid=59296&pageid= Accessed September 23, Burkhardt MC, Beck AF, Conway PH, Kahn RS, Klein MD. Enhancing Accurate Identification of Food Insecurity Using Quality-Improvement Techniques. Pediatrics. 2012;129(2):e504-e Lane W, Dubowitz H, Feigelman S, Poole G. The Effectiveness of Food Insecurity Screening in Pediatric Primary Care. Int J Child Heal Nutr. 2014;3(3): The Prescription Program Learning Collaborative. Wholesome Waves. October Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to Measuring Household Food Security Hunger Vital Sign. Children s Health Watch. Accessed October 4, Gucciardi E, Vahabi M, Norris N, Del Monte JP, Farnum C. The Intersection between Food Insecurity 23

24 and Diabetes: A Review. Curr Nutr Rep. 2014;3(4): doi: /s Connell CL, Nord M, Lofton KL, Yadrick K. Food Security of Older Children Can Be Assessed Using a Standardized Survey Instrument. J Nutr. 2004;134(May): Supplemental Nutrition Assistance Program (SNAP). USDA Food Nutr Serv. gov/snap/eligibility. Accessed September 23, Texas Temporary Assistance for Needy Families (TANF). Benefits.gov. benefits/benefit-details/1679. Accessed September 23, Women, Infants and Children (WIC). USDA Food Nutr Serv. Accessed September 23, The National School Lunch Program. USDA Food Nutr Serv. default/files/cn/nslpfactsheet.pdf. Accessed September 23, The School Breakfast Program. USDA Food Nutr Serv. files/sbp/sbpfactsheet.pdf. Accessed September 23, How to Participate in Summer Meals. USDA. SFSP-Fact-Sheet.pdf. Accessed September 23, Texas Disaster Nutrition Assistance. USDA Food Nutr Serv texas-disaster-nutrition-assistance. Accessed November 11, USDA Eases WIC Food Package Rules for Texas Participants Affected by Harvey. USDA Accessed November 11,

25 APPENDIX A. RESOURCES FOR FOOD INSECURITY The following section provides an overview of resources that are available for food insecure families in Houston and Harris County including federal nutrition programs, local resources, farmers markets that accept SNAP/EBT, local resources for food insecure children, local resources for food insecure seniors, disaster resources, and national resources. FEDERAL NUTRITION PROGRAMS Program Description Eligibility Requirements SNAP 44 Supplemental Nutrition Assistance Program (SNAP) provides a monthly supplement for purchasing nutritious food. Participants will receive a debit card to purchase groceries. There are income limits; income eligibility should be assessed. Individuals must be employed or seeking employment. Citizens and most legal immigrants. TANF 45 The Temporary Assistance for Needy Families (TANF) program provides financial and medical assistance to needy dependent children and the parents or relatives with whom they are living. Resident of Texas. Pregnant or a parent of a child under 19 years of age, US national, citizen, legal alien, or permanent resident. Low income, be unemployed or underemployed. WIC 46 The Women, Infant, and Children (WIC) program provides participants with checks, vouchers, or an electronic card to purchase healthy foods and formula. Resident of Texas. Pregnant and postpartum women, infants, and children up to age 5. Identified as nutritional risk by a health professional. At or below 185% of the federal poverty line. National School Lunch Program 47 School Breakfast Program 48 Summer Food Service Program 49 The National School Lunch Program provides nutritionally balanced lunch to qualified children in schools and childcare centers each school day. The School Breakfast Program provides nutritionally balanced breakfast to qualified children each school day. The Summer Food Service Program provides free meals and snacks to low-income children during the summer months. Children from families with incomes at or below 130% of the federal poverty level are eligible for free meals. Those with incomes between 130% and 185% of the federal poverty level are eligible for reduced price meals. Families should apply through the child s school. Children from families with incomes at or below 130% of the federal poverty level are eligible for free meals. Those with incomes between 130% and 185% of the federal poverty level are eligible for reduced price meals. Sites can apply to participate in the program if they reside in an eligible area. 25

26 LOCAL RESOURCES Houston Food Bank The Houston Food Bank is America s largest food bank in distribution to its network of 600 hunger relief charities in 18 southeast Texas counties. Houston Food Bank provides 83 million nutritious meals to food pantries, soup kitchens, senior centers and other agencies, feeding 800,000 people each year. Fresh produce, meat, and nonperishables are distributed from the warehouse, and hot meals are prepared and distributed from the Keegan Kitchen. Additional community services range from nutrition education to assistance with food stamp applications and hands-on job training Agency Locator, Houston Food Bank The Houston Food Bank maintains an interactive online database and map of most of the food pantries in Houston and Harris County. Providers can enter their zip code for a list of nearby pantries. The database is accessible at Client Assistance Program, Houston Food Bank Houston Food Bank s Client Assistance Program (CAP) provides application assistance for SNAP (Supplemental Nutrition Assistance Program) and other social, health, and personal services. CAP staff can help you with a client s current needs and can submit applications electronically to the State. In some cases, CAP staff may issue Electronic Benefit Transfer (EBT) cards to clients, which can help expedite receipt of benefits after eligibility has been approved on the State level is a helpline run by the United Way of Greater Houston that is available 24 hours a day, 7 days a week to help connect residents in Greater Houston with services and resources ranging from child care and rent assistance to food stamps. In 2016, answered over 900,000 calls for help. Providers and patients can call or visit for food programs and pantries. Types of food programs include community gardening, congregate meals, food banks, food cooperatives, food lines, food pantries, food stamps, food vouchers, formula/baby food, home delivered meals, and soup kitchens Feeding America s Find Your Local Food Bank For practices and patients that are outside of the Houston Food Bank s service area, Feeding America s website enables users to locate the closest food banks to a zip code. Hunger Free Texans Hunger Free Texans mission is to keep members of the public well by reducing hunger and increasing health and nutrition in Texas through collective impact and education. Hunger Free Texans hosts educational events that focuses on the connection between food, food access, a healthier diet, and health outcomes. Target Hunger Target Hunger operates five food pantries that service individuals and families who need food assistance in zip codes 77016, 77020, 77026, and They also provide emergency food relief in times of crisis and natural disasters. Target Hunger food pantry clients receive a distribution of nutritious groceries, including proteins and fresh produce, once a month. This supplemental grocery distribution 26

27 is meant to cover the five to seven-day gap at the end of the month when SNAP benefits have been exhausted. Target Hunger hosts Community and Educational Food Fairs each month at four of the food pantry locations. In collaboration with the Houston Food Bank, the general public is invited to participate in mini-educational workshops on topics such as health and nutrition, safety, legal matters, and other informational topics. Each participant is then provided with a healthy distribution of 30 to 40 pounds of fresh, seasonal produce FARMERS MARKETS THAT ACCEPT SNAP/EBT Get Moving Houston Farmers Market Time/date varies by location and season. Visit gohealthyhouston.org/farmersmarket/ for an updated schedule. *Denver Harbor Multi Service Center 6402 Market St, Houston, TX *Acres Home Multi Service Center 6719 W Montgomery St, Houston, TX *Sunnyside Multi Service Center 9314 Cullen St, Houston, TX *Magnolia Multi Service Center 7037 Capitol St, Houston, TX *Northeast Multi Service Center 9720 Spaulding St, Houston, TX *Southwest Multi Service Center 6400 High Star Dr, Houston, TX, East End Farmers Market Navigation Blvd, Houston, TX Open every Sunday from 10am-2pm The Palm Center Farmers Market Griggs Rd, Houston, TX Open every 2nd and 4th Saturday from 9am-1pm Plant It Forward Farm Stands Willowbend Blvd, Houston TX Open every Tuesday from 3:30-5:30pm Plant It Forward Farm Stands, Fondren Fondren Rd, Houston TX Open every Tuesday & Thursday from 8:30am-10:30am 6-8pm Hope Farms Farm Stand Scott Street, Houston, TX Open every Saturday from 8:30am 11:30am Blodgett Urban Garden Farm Stand Blodgett St, Houston, TX Times vary. Check TSU Urban Farms Facebook page for dates/times Urban Harvest Farmers Market on Eastside Richmond, Houston, TX Open every Saturday from 8am-12 pm, expected to become SNAP accessible by November 2017 LOCAL RESOURCES FOR FOOD INSECURE CHILDREN Backpack Buddy, Houston Food Bank Many children rely on school meals for breakfast and lunch during the school year. During breaks, such as weekends and holidays, many of these children go home to little or no meals. The Houston Food 27

28 Bank s Backpack Buddy program works to fill that gap by providing nutritious, child-friendly food for school children to take home over the weekend. Through the Backpack Buddy program, the Houston Food Bank works in partnership with participating schools, school district delivery sites, and other community partners to ensure that the food sacks are distributed to children on every Friday during the school year Brighter Bites Brighter Bites delivers fresh fruits and vegetables directly to kids at participating schools, preschools, and after-school programs. Participants enrolled in these schools/programs receive two bags per family. One bag contains fruit and one for vegetables. Brighter Bites combines produce distributions with nutrition education, recipes, and food demonstrations. The Brighter Bites program is divided into three eight-week seasons that occur during the Fall, Spring, and Summer Kids Café, Houston Food Bank Kids Cafe is one of the nation s largest nutrition education programs providing children with the nourishment they may not get at home. Kids Cafe provides nutritious meals and snacks to children at after school programs. Children also receive food safety lessons, nutrition education and hands-on instruction to help create healthy lifestyles. In the summer, the number of children served doubles as the Houston Food Bank converts to the Summer Food Service Program. Membership in an after-school program is required to participate in Kids Cafe Kids Meals Houston Preschool-aged children often fall through the gap of social services addressing food insecurity. Kids Meals Houston addresses hunger and food insecurity for children ages five and younger who cannot access school free meal programs. Each weekday, Kids Meals Houston delivers approximately 2,500 healthy meals to Houston s hungriest preschool-aged children. When school is out, every child up to age 18 in these homes also receives a healthy meal from Kids Meals up to 4,000 kids per day. The six vans deliver the meals Monday through Friday to children enrolled in the program. Kids Meals Houston currently serves six Houston-area routes that target zip codes all located within Beltway 8, where the need is critical L.I.F.E. Houston L.I.F.E. Houston helps families meet the nutritional needs of their babies by providing infant formula and baby food along with education on infant nutrition to families in need. The program provides 100,000 infant feedings each year LOCAL RESOURCES FOR FOOD INSECURE SENIORS Meals on Wheels, Interfaith Ministries of Greater Houston Interfaith Ministries (IM) Meals on Wheels for Greater Houston program provides home-delivered meals to disabled adults and homebound clients over 60 years of age. The program also delivers weekend meals and a week s worth of breakfast to over 1,100 of the most frail and isolated clients. This nutritional support helps people stay independent and in their own homes. IM reaches out to the remote areas of Harris County, serving elders across the county. IM also partners with organizations in Galveston, Liberty, and Montgomery Counties to deliver meals

29 Senior Box Program, Houston Food Bank The Senior Box Program is funded through the Commodity Supplemental Food Program, a federal program designed to improve the health and nutrition of income eligible seniors. Seniors receive a box of food each month with a retail value of $50, which helps stretch their fixed incomes to keep food on the table. Eligible seniors are Harris County residents over 60 years old with a total monthly income no more than $1,308 for a household of one or $1,760 for a household of two DISASTER RESOURCES Additional resources may be available to residents after disasters, such as hurricanes. These resources include D-SNAP, extended SNAP recertification periods, automatic food loss replacement, expanded WIC and SNAP allowable purchases, and free school meals for all children in an affected area. Disaster Supplemental Nutrition Assistance Program (D-SNAP) Disaster Supplemental Nutrition Assistance Program (D-SNAP) offers short-term food assistance benefits to families recovering from a disaster. 35 Beneficiaries include families that were not previously receiving SNAP, reside in a declared disaster area, suffered loss from the disaster, and meet certain income limits. Families receive up to two months of benefits which are provided within three days of applying. In addition, the Houston Food Bank works with nonprofits across the region to set up temporary pantries to increase the availability and accessibility of food after a disaster. SNAP recertification Families with SNAP recertification due dates that fall within a disaster recovery period are afforded eligibility extensions. In these circumstances, benefits are continued for a six-month period. Additionally, families are granted a food replacement allowance to re-purchase goods that may have been lost as a result of a disaster. Both of these benefits can be automatically granted by Health and Human Services (HHS) to disaster affected areas and do not require recovering families to take additional steps to apply. 50 Expanded food choices During a disaster, HHS can expand the allowable list of approved purchase items under SNAP and WIC. Under SNAP s Hot Food Waiver, benefits can be used to purchase prepared (cooked) foods for immediate consumption since families may be without means to prepare their own meals. Allowable WIC purchases expand to include a variety of eggs and bread not restricted by type or quantity. Fluid milk can be substituted for any type of available fat content that is in stock with the grocery retailer. 51 Lastly, HHS may allow schools more flexibility in providing free meals to students regardless of their ability to pay. Schools may also request permission to send food home with children as opposed to restricting meal delivery to on-site consumption. Schools are allowed to seek full reimbursement for provided meals. 50 NATIONAL RESOURCES AAP toolkit - Addressing Food Insecurity: A Toolkit for Pediatricians The American Academy of Pediatrics (AAP) is an organization of 66,000 pediatricians committed to optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults. In 2015 they released a policy statement Promoting Food Security for All Children and their 2017 toolkit in partnership with FRAC (see below) reviews background, guidelines and recommended steps for implementing food insecurity screening into a clinical practice, and advocacy actions pediatricians can take. 29

30 AARP toolkit - Implementing Food Security Screening and Referral for Older Patients in Primary Care: A Resource Guide and Toolkit The American Association of Retired Persons (AARP) is a nonprofit, nonpartisan, social welfare organization with a membership of nearly 38 million. Since 2011, AARP Foundation s Drive to End Hunger campaign has been raising awareness about the problem of food insecurity among older adults, meeting the immediate daily food needs of hungry seniors, and working to establish permanent solutions to end senior hunger once and for all. Their 2016 toolkit reviews background, guidelines, and recommended steps for implementing food insecurity screening into a health system or primary care practice, and lists resources for older adults. Food Research & Action Center The Food Research & Action Center (FRAC) is the leading national organization working for more effective public and private policies to eradicate domestic hunger and under-nutrition. They lead efforts to communicate the connections among poverty, hunger, and obesity among low-income people; conduct research to document the extent of hunger, its impact, and effective solutions; seek stronger federal, state, and local public policies that will reduce hunger, undernutrition, and obesity; monitor the implementation of laws and serve as a watchdog of programs; provide coordination, training, technical assistance, and support on nutrition and anti-poverty issues to a nationwide network of advocates, service providers, food banks, program administrators and participants, and policymakers; and conduct public information campaigns to help promote changes in attitude and policies. Feeding America Feeding America is a nationwide network of 200 food banks and 60,000 food pantries and meal programs that provides food and services to people each year. They are the nation s largest domestic hunger-relief organization. Their efforts span nearly every community in all 50 states, Washington D.C., and Puerto Rico. Map the Meal Gap Map the Meal Gap is an initiative of Feeding America that generates two types of community-level data: county-level food insecurity and child food insecurity estimates by income categories; and an estimate of the food budget shortfall that food insecure individuals report they experience. Wholesome Wave Wholesome Wave empowers under-served consumers to make better food choices by increasing affordable access to healthy produce. They make fruits and vegetables affordable through two flagship programs: they double the value of food stamps when spent on fruits and vegetables and they work with doctors to prescribe produce. Their network includes 1,400+ farmers markets and grocery stores in 48 states and counting. Hunger and Health Hunger and Health is an initiative of Feeding America that works to educate, connect, and engage crosssector professional on the intersection of food insecurity, nutrition, and health. 30

31 APPENDIX B. HARRIS COUNTY BUILD PARTNERSHIP S FOOD PRESCRIPTION CLINIC Food Prescription Program (Food Rx) Participant Information Name: Last First M.I. Participant ID: PHC Issue Date: To be completed by Clinic Staff ONLY Designee authorized by you to pick up the Food Rx on your behalf, if needed. Substitute Shopper : Expiration Date: Last First M.I. To be completed by PCM Volunteers ONLY Redemption Your Food Prescription is worth 30 pounds of produce plus 4 additional Food Rx friendly items every two weeks for 6 months (a total of 12 weeks of redemption) beginning the first time you redeem at the scholarship pantry or until end of program (May 31st, 2017). Select at least two fruits and two vegetables each time you redeem. Your Food Rx is redeemable only at the Pasadena Community Ministry Scholarship Food Pantry. Pasadena Community Ministry Every Thursday 9 AM - 12PM Scholarship Pantry 3 PM - 6PM 2301 S. Houston Road 1 Pasadena, TX and 3 rd Saturday of 11 AM - 2 PM the month *** Please use entrance door located on Travis Street Food Rx Redemption Tracker Week # MM/DD/YYYY Week # MM/DD/YYYY Week # MM/DD/YYYY Week 1 Week 6 Week 11 Week 2 Week 7 Week 3 Week 8 Week 4 Week 9 Week 5 Week 10 ** On the last redemption (Week 12), you will receive an extra 15lbs of produce and 2 additional Food Rx friendly items 31